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For over 225 years, NHCMA has represented the voice of New Haven County physicians and their patients. We offer not just a wealth of benefits, like networking events, discounts, action alerts and workshops, we also give you and your patients a way to get involved in the fight for the future of health care.

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NHCMA's Event Calendar includes a variety of valuable seminars and events. Our goal is to offer our physician members and their staffs the knowledge and resources necessary to manage a successful practice.

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Physicians Who Refuse to Enroll, Opt-Out, or Submit Claims to Medicare

National Government Services has received several inquiries asking whether physicians may refuse to enroll in Medicare and refuse to submit claims to Medicare when they furnish Medicare-covered services to beneficiaries. These unenrolled physicians would prefer if beneficiaries were to submit claims on their own using the CMS-1490S form.

In order to stay in compliance with Medicare law, a physician who treats a Medicare beneficiary for a Medicare-covered service must either 1.) enroll in Medicare and submit a claim on that beneficiary's behalf for those services; 2.) opt-out of Medicare and enter into a private contract with the beneficiary for those services; or 3.) furnish the Medicare-covered services for free. A physician who wants to treat (and receive payment from) a Medicare beneficiary will stay in compliance with the law by either enrolling in Medicare and filing claims on the beneficiary's behalf or by opting-out of Medicare and entering into a private contract with the beneficiary. Moreover, in order to receive a Medicare payment for covered items or services - whether directly from Medicare or from the beneficiary who is, in turn, reimbursed by Medicare, - a physician must be enrolled in the Medicare program. See the Code of Federal Regulations (CFR) title 42, part 424, section 500 et seq. for the regulations regarding establishing and maintaining Medicare billing privileges.

A physician can enroll in Medicare and choose to be either participating or nonparticipating. Physicians who enroll in Medicare and also enter into a participating physician agreement with Medicare agree to always accept assignment for all Medicare-covered services. Physicians who enroll in Medicare but do not enter into a participating physician agreement with Medicare are characterized as nonparticipating physicians. Nonparticipating physicians choose on a claim-by-claim basis whether or not to accept assignment. If a nonparticipating physician does not accept assignment, then Medicare pays the beneficiary directly and the nonparticipating physician may bill the beneficiary up to the limiting charge amount.

With the exception of those who have complied with the opt-out procedures, when a physician furnishes a service that is covered by Medicare, the physician is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Act. Therefore, if a physician charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the physician must submit a claim to Medicare. Physicians who violate the mandatory claim submission rules may receive a fine of up to $2,000 (see section 1848(g)(4)(B) of the Act). Additionally, pursuant to CMS IOM Publication 100-02, Medicare Policy Benefit Manual, Chapter 15, Section 40 physicians "...are not allowed to charge beneficiaries in excess of the limits on charges that apply to the item or service being furnished". This requirement applies regardless of whether or not a claim is submitted to Medicare for the covered service. Physicians who violate Medicare's limiting charge are subject to being excluded from the Medicare Program for up to five years or subject to a civil monetary penalty of not more than $10,000 (see section 1848(g)(1)(B) of the Act).

Therefore, when physicians who are not enrolled in Medicare ask beneficiaries to submit claims on their own using the form CMS-1490S, those physicians are in violation of Medicare law and unenrolled physicians who engage in this type of practice are subject to the penalties referenced above. As mentioned above, if a physician that is not enrolled in Medicare wishes to avoid being subject to the mandatory claim submission and limiting charge rules, then that physician should opt-out of Medicare. Physicians and non-physician practitioners who opt-out are excused from those rules but only when they maintain compliance with all of the requirements for opting-out.